Quality Life Services-mercer.

“Staff did not immediately report suspected abuse to the local Area Agency on Aging. An incident occurred on 02/26/2025 at approximately 6:15 a.m. involving an inappropriate comment made by staff person B to staff person A in the presence of a resident. The incident was reported to facility staff at 10:30 a.m. but was not reported to the Older Adult Protective Services in Mercer County until 03/20/2025.”

“The facility did not report the incident to the Department's personal care home regional office or complaint hotline within 24 hours. An incident of alleged abuse occurred on 02/26/2025 at approximately 6:15 a.m., but was not reported to the Department in accordance with reporting requirements.”

“A resident was not treated with dignity and respect. On 02/26/2025 at approximately 6:15 a.m., staff person B made an inappropriate comment to staff person A while a resident was present and in need of personal hygiene assistance, which demeaned the resident.”

“A bathroom without an operable outside window was not equipped with an exhaust fan for ventilation.”

“Two spray bottles containing clear liquid labeled "odor eliminator" and yellow liquid labeled "multi-surface" with handwritten labels were stored on an unlocked, unattended, and accessible housekeeping cart in the common area of the secure dementia care unit.”

“An 8oz pump bottle of Medline Spectrum Advanced Gel Hand Sanitizer with a poison control warning label was unlocked, unattended, and accessible on a housekeeping cart in the common area of the secure dementia care unit, and not all residents had been assessed as capable of safely using or avoiding poisonous materials.”

“The metal surface of baseboard heaters in shower room #1 measured 132 degrees Fahrenheit, exceeding the 120-degree threshold, and there were no protective guards in place to prevent residents from coming into contact with the heat source.”

“There was no trash can in the bathroom of bedroom #217, failing to meet the requirement for covered trash receptacles in bathrooms to prevent penetration of insects and rodents.”

“An incident involving a resident who fell in the bathroom and sustained facial bruising and head injury was not reported to the Department within 24 hours as required. The incident occurred on an unspecified date but was not reported to DHS until after the 24-hour reporting window had passed.”

“A resident who required assistance with toileting per her assessment and support plan did not receive this assistance and fell in the bathroom, sustaining facial bruising, nose bruising, and a head bump. The resident was found scooting on her bottom across the bathroom floor with the handrail/seat boost assistive device displaced from its original position.”

“Staffing levels were inadequate to meet resident needs and emergency evacuation requirements. The facility had only 1 staff person in the PCH and 1 in the ALR during overnight hours (10:00 p.m. to 6:00 a.m.) to evacuate 50-53 total residents, including multiple residents requiring assistance from 1-3 staff members for evacuation, despite a maximum safe evacuation time of 5 minutes and 35 seconds.”

“Resident #1's support plan did not address how the home would meet the resident's documented need for assistance with toileting through required 2-hour incontinence checks.”

“Three residents admitted to the Secured Dementia Care Unit (Residents #1, #3, and #4) had medical evaluations completed outside the required 60-day window prior to admission.”

“Staff failed to immediately report suspected abuse of three residents to the local Area Agency on Aging. Reports were delayed by several days despite incidents being reported to the administrator on the same day.”

“Staff person A was not immediately suspended or placed under a supervision plan following allegations of abuse involving two residents with serious findings including a buckle fracture. The staff member continued to provide unsupervised direct care for several days before suspension.”

“Resident #1 required assistance with toileting as indicated in the assessment and support plan but did not receive this assistance on 07/20/2023, resulting in the resident being found in feces-contaminated condition.”

“Resident #4's initial assessment did not include documentation that the resident resides on the Secured Dementia Care Unit and had suicidal ideation.”

“Resident #2's assessment did not include documentation of the resident's need for assistance with toileting and issues with irritability as indicated by staff interviews.”